Sex on PrEP: qualitative findings from the iPrEx open label extension (OLE) in the US

1Gladstone Institute of Gladstone & Immunology, San Francisco, United States, 2Gladstone's iPrEx Team, Storrs, United States, 3San Francisco Department of Public Health, San Francisco, United States, 4Gladstone Institute of Virology and Immunology, San Francisco, United States, 5Stroger Hospital of Cook County, Psychiatry, Chicago, United States, 6Fenway Institute, Boston, United States

Background: One of the major concerns about the use of pre-exposure prophylaxis (PrEP) is that the protective benefits may be negated by increases in other behaviors that offset these benefits (risk compensation). Others argue that taking PrEP may increase behaviors that promote protection of sexual health (prevention synergy). To better understand sexual behavior in the context of PrEP, we undertook a qualitative study of sexual experiences among iPrEx OLE participants in the US.Methods: We conducted in-depth interviews (IDIs) with a purposeful sample of iPrEx OLE participants (MSM and transwomen). Interviews were audio recorded and transcribed. We analyzed the data using the principles of grounded theory.Results: From April-September 2012, we conducted 60 IDIs (20 SF, 19 Boston, 21 Chicago) with participants on PrEP (mean age =36 51% white; 43% black, 6% other). Pre-PrEP sexual practices ranged from occasionally foregoing condoms characterized as “slip ups” to routinely foregoing condoms with friends/partners and finally, those who rarely used condoms. Overall, participants did not report significant changes to their sexual behaviors once they began taking PrEP. Rather, participants experienced a sense of relief or reprieve from HIV-related stress. Specifically, participants described feeling “more carefree”, “more comfort” and a “relaxed attitude”, versus pre-PrEP experiences of anxiety and fear after sexual encounters, even those with low risk. This unburdening of fear did not appear to lead to condomless sex. A subset of participants described a greater awareness of their behaviors and an increase in HIV prevention practices.Conclusions: OLE participants on PrEP felt a sense of security and less free-floating fear of HIV. These qualitative data support quantitative analyses showing no increase in risk taking among PrEP users. No longer living under the threat of HIV is a significant benefit that has not been adequately explored in prevention research.